MEDICARE: MRS. CATHERINE CORISH GRANT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	004290	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023017795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CATHERINE CORISH GRANT PA-C

Provider Business Mailing Address
First Line	:	114 GREAT OAKS WAY
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-5461
Country	:	US
Telephone Number	:	912-596-8868
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 EXCHANGE STREET
Second Line	:	SUITE B-7
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324
Country	:	US
Telephone Number	:	912-756-2273
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	03/12/2009

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